All of the 50 states of the United States have laws governing childhood vaccinations; 48 allow for religious exemptions, while 19 also offer exemptions based on some sort of personal philosophy. Recent disease outbreaks have caused these states to reconsider philosophical exemptions. However, we cannot, consistent with the U.S. Constitution, give preference to religion by creating religious exemptions only. The Constitution requires states to put religious and nonreligious claims on equal footing. Given the ubiquity of nonreligious objections to vaccination, I (...) conclude that the best response is to remove all exemptions, as two states have already done. But removing exemptions should not end our concern for children. Removing exemptions only bars children from public schools; it still leaves them unvaccinated, a danger to others, and reliant on whatever nonpublic schooling is available. If public school attendance is not enough of an incentive for vaccine reluctant parents, perhaps we should look into stronger measures. (shrink)

ABSTRACT:This essay explores a more inclusive and equitable interpretation of "religion" within the context of religious vaccine exemptions. The existing literature critiques the prevalent interpretation of the meaning of religion in religious exemption cases, but frequently overlooks the importance of incorporating the concept of "lived religion." This essay introduces the concept of lived religion from religious studies, elucidates why this lived religion approach is crucial for redefining "religion," and illustrates its application in the domain of religious vaccine (...) exemptions. The author contends that broadening the meaning of religion by employing the concept of lived religion would promote a more inclusive and equitable implementation of religious vaccine exemptions. (shrink)

In a recent paper published in this journal, Giubilini, Douglas and Savulescu argue that we have given insufficient weight to the moral importance of fairness in our account of the best policies for non-medical exemptions to childhood immunization requirements. They advocate for a type of policy they call Contribution, according to which parents must contribute to important public health goods before their children can receive NMEs to immunization requirements. In this response, we argue that Giubilini, Douglas and Savulescu give insufficient (...) weight to the moral importance parental liberty in ways that count against their preferred type of NMEs policy and threaten public support for mandatory vaccination laws and public health initiatives generally. (shrink)

In a paper recently published in this journal, Navin and Largent argue in favour of a type of policy to regulate non-medical exemptions from childhood vaccination which they call ‘Inconvenience’. This policy makes it burdensome for parents to obtain an exemption to child vaccination, for example, by requiring parents to attend immunization education sessions and to complete an application form to receive a waiver. Navin and Largent argue that this policy is preferable to ‘Eliminationism’, i.e. to policies that do (...) not allow non-medical exemptions, because Inconvenience has been shown to maintain exemption rates low while not harming parents by forcing them to do something that goes against their beliefs. We argue that it is at least doubtful that Inconvenience is ethically preferable to Eliminationism: while the latter disregards the value of liberty, Inconvenience disregards the value of fairness in the distribution of the burdens entailed by the preservation of a public good like herd immunity. We propose a variant of Inconvenience, which we call ‘Contribution’, which we think is preferable to the versions of Inconvenience discussed by Navin and Largent in that it successfully strikes a balance between the values of parents’ liberty, fairness and expected utility. (shrink)

Courses on bioethics and the law traditionally have focused their coverage on ethical issues arising from individual patients’ encounters with the medical care system, but the course also provides an excellent opportunity to expose students to ethical issues arising at the intersection of medical care and public health. The following materials were assembled for use near the end of a semester-long law school course in Bioethics & Law. I taught the course relying heavily on problems contained in Barry R. Furrow (...) et al., Bioethics: Health Care Law and Ethics, 7th ed., which was the primary text for the course. (shrink)

This study examines the procedural ethical considerations surrounding religious exemptions to Covid vaccine mandates, specifically focusing on immigrant healthcare personnel (HCP) and HCPs of color. It emphasizes communication issues with applicants by investigating exemption applications and their accompanying guidelines. While there is extensive literature on the ethical implications of religious exemptions, a notable gap remains in addressing the procedural aspects of religious exemption applications and their reviewing processes. The study scrutinized religious exemption application forms and accompanying (...) guidelines from 32 selected non-teaching and teaching hospitals for the years 2022–2023. The findings highlight significant variability in exemption application criteria and processes across institutions. Importantly, many application forms lacked comprehensive procedural information, which may result in subjective evaluations and potential misinterpretations of non-Western and non-mainstream religious beliefs, especially those of immigrant HCPs and HCPs of color. The study proposes various strategies to advocate for more equitable and transparent procedures, underlining the significance of diversity, equity, and inclusion in the religious exemption review process for vaccine mandates. (shrink)

The rapid development and roll-out of COVID-19 vaccines has been a surprising success of the pandemic and has likely saved hundreds of thousands of lives. Although most people were eager to receive a vaccine, many jurisdictions introduced mandates to ensure rapid uptake in the population, especially among key workers including healthcare workers. In some instances, individuals who can prove they have recovered from COVID-19 have been exempt from vaccine mandates, but in other cases such exemptions have not been (...) made. Pugh et al argue that such exemptions for those already immune ought to be included in COVID-19 vaccine mandates.1 They review the evidence on infection-induced and vaccine-induced immunity and show that that there is not evidence that vaccines offer better protection against severe COVID-19 or of SARS-CoV-2 infection. They argue that to treat people differently based on the source of their COVID-19 immunity is wrongful discrimination, with this discrimination bringing harms in the form of unjust restriction of liberty and negative consequences such as lost employment. I agree with Pugh et al ’s view that, given the available evidence, infection-induced immunity to SARS-CoV-2 ought to be treated as equivalent to vaccine-induced immunity for the purposes of most COVID-19 vaccine mandates. However, their article highlights the need for clarity in the rationale for mandates. This clarity is necessary to be able to identify when exemptions are appropriate. It may be the case that in some instances infection-induced immunity ought not to be grounds for exemption. Pugh et al ’s argument also suggests that collection of data on infection-induced immunity may be a requirement for ethical vaccine mandates. To be confident in such exemptions, we need evidence that infection-induced immunity is comparable to vaccine-induced immunity in the …. (shrink)

Under federal law, an individual religious exemption from vaccines is valid when it is based on subjective, sincere beliefs rooted in religion but not dependent on the existence, veracity, or accurate understanding or application of denominational tenets or doctrines. Despite the subjective nature of the individual religious exemption, Catholic institutions may recognize or deny individual religious exemptions on the basis of the institution’s own religious exemptions. For example, under the doctrine of the common good, the significant risk to (...) the community presented by non-vaccinated individuals could be grounds for an institution to deny an individual’s otherwise valid religious exemption. This paper attempts to clarify the decision-making framework used by law to balance individual religious exemptions and compelling state interests, then proposes a similar decision-making framework, consistent with Catholic moral principles, for religious institutions to use when balancing individual conscience objections and compelling duties to society. (shrink)

Background: While employers are increasingly considering and implementing COVID-19 vaccination requirements, little is known about the reasons offered by employees seeking religious exemptions.Methods: We conducted a mixed methods analysis of all the requests for religious exemptions submitted during the initial implementation of a COVID-19 vaccination requirement at a single academic medical center in the United States.Results: Five hundred sixty-five (3.4%) employees requested religious exemptions. At least 305 (54.0%) requesters had job titles suggesting that they had direct patient contact. Four hundred (...) ninety-nine (88.3%) of requesters self-identified as Christian, of whom 120 (21.2%) identified as Roman Catholic. Requesters offered 0 to 8 (mean 2.7) categories of reasons for their request. The most frequently stated reasons pertained to the use of fetal cell lines in vaccine development and manufacturing (382, 67.6%), interest in maintaining purity (221, 39.1%), or belief in divine healing (172, 30.4%). Some requesters also volunteered evidence of the sincerity of their beliefs including examples of their religious practices (116, 20.5%), other practices (66, 11.7%), and emotional states (32, 5.7%). One hundred fifty-two applications (26.9%) contained text copied without attribution, primarily from sample religious exemption request letters available on the Internet.Conclusions: Most requesters focused on the use of fetal cell lines in the development or manufacturing of the vaccines as the justification for their request. The development of vaccines that are not reliant on fetal cell lines may increase vaccination rates. Understanding reasons for religious exemption requests may inform vaccine education and vaccination policies. (shrink)

Objective Having failed to achieve adequate influenza vaccination rates among employees through voluntary programmes, healthcare organisations have adopted mandatory ones. Some programmes permit religious exemptions, but little is known about who requests religious objections or why. Methods Content analysis of applications for religious exemptions from influenza vaccination at a free-standing children’s hospital in Cincinnati, Ohio, USA during the 2014–2015 influenza season. Results Twelve of 15 260 employees submitted applications requesting religious exemptions. Requestors included both clinical and non-clinical employees. All requestors (...) voluntarily identified their religious affiliation, and most were Christian. Content analysis identified six categories of reasons used to justify an exemption: risks/benefits, ethical/political, lack of direct patient contact, providence, purity and sanctity of life. Individuals articulated reasons in 1–5 categories. The most frequently cited category was purity; the vaccine and/or its mode of administration were impure, or receiving the vaccine would make the individual impure. Two individuals asserted that the vaccine contained cells derived from aborted human fetuses. Individuals also volunteered information supporting the sincerity of their beliefs including distress over previous vaccination and examples of behaviour consistent with their specific objection or their general religious commitment. All requests were approved. Conclusions Less than 0.1% of employees requested religious exemptions. Partnering with religious leaders and carefully correcting erroneous information may help address requestors’ concerns. (shrink)

This article argues that the Supreme Court should not require a religious exemption from vaccine mandates. For children, who cannot yet make autonomous religious decision, religious exemptions would allow parents to make a choice that puts the child at risk and makes the shared environment of the school unsafe — risking other people’s children. For adults, there are still good reasons not to require a religious exemption, since vaccines mandates are adopted for public health reasons, not to (...) target religion, are an area where free riding is a real risk, no religion actually prohibits vaccinating under a mandate, and policing religious exemptions is very difficult. (shrink)

In February 1997, the Committee on Bioethics of the American Academy of Pediatrics updated its position on religious exemptions to medical care. In its earlier statement, the committee noted that forty-four states have religious exemptions to the child abuse and neglect statutes, and they argued for the repeal of these exemptions. The committee did not indude in its statement a position on religious exemptions to childhood immunization requirements that exist in forty-eight states, although this issue was discussed in committee meetings. (...) In its revised statement, the committee concluded that “The AAP does not support the stringent application of medical neglect laws when children do not receive recommended immunizations.” In this paper, we consider whether failure to immunize one's child is a form of medical neglect and, if so, whether states should repeal their religious exemptions to the immunization statutes. We argue that failure to vaccinate a child properly is medical neglect. (shrink)

In February 1997, the Committee on Bioethics of the American Academy of Pediatrics updated its position on religious exemptions to medical care. In its earlier statement, the committee noted that forty-four states have religious exemptions to the child abuse and neglect statutes, and they argued for the repeal of these exemptions. The committee did not indude in its statement a position on religious exemptions to childhood immunization requirements that exist in forty-eight states, although this issue was discussed in committee meetings. (...) In its revised statement, the committee concluded that “The AAP does not support the stringent application of medical neglect laws when children do not receive recommended immunizations.” In this paper, we consider whether failure to immunize one's child is a form of medical neglect and, if so, whether states should repeal their religious exemptions to the immunization statutes. We argue that failure to vaccinate a child properly is medical neglect. (shrink)

Respect for autonomy is problematic in relation to public health programmes such as vaccination, as the success of such programmes depends on widespread compliance. European countries have different policies for dealing with objectors to vaccination programmes. In some countries compliance is compulsory, while in others objectors are exempted or allowed to enter the programme under specific conditions. In this paper I argue that the objectors should not be treated as a homogenous group as is done in the above-mentioned policies. Objectors (...) have different arguments for not participating in vaccination programmes. Considering the value of respect for autonomy, some but not all of these arguments need to be accommodated by authorities. The concept of 'narrative autonomy' provides criteria to distinguish between tenable and untenable claims to the right to refuse vaccination. Narrative autonomy understands autonomy as essentially linked to identity, as this provides the moral framework with which we assess our first-order preferences. The above-mentioned concept of autonomy is derived from the concept of narrative identity as described by Marya Schechtman. She suggests that the application of the Articulation Constraint and the Reality Constraint enables us to establish the validity of personal narratives. Additionally, form and content features of identity, as proposed by Anthony Laden, will be used as criteria to establish the compatibility of the defectors' arguments with shared scientific and political values. Such compatibility is essential to accommodate respect for autonomy in the context of public health. (shrink)

Parents in the US and other societies are increasingly refusing to vaccinate their children, even though popular anti-vaccine myths – e.g. ‘vaccines cause autism’ – have been debunked. This book explains the epistemic and moral failures that lead some parents to refuse to vaccinate their children. First, some parents have good reasons not to defer to the expertise of physicians, and to rely instead upon their own judgments about how to care for their children. Unfortunately, epistemic self-reliance systematically distorts (...) beliefs in areas of inquiry in which expertise is required. Second, vaccine refusers and mainstream medical authorities are often committed to different values surrounding health and safety. For example, while vaccine advocates stress that vaccines have low rates of serious complications, vaccine refusers often resist vaccination because it is ‘unnatural’ and because they view vaccine-preventable diseases as a ‘natural’ part of childhood. Finally, parents who refuse vaccines rightly resist the utilitarian moral arguments – ‘for the greater good’ – that vaccine advocates sometimes make. Unfortunately, vaccine refusers also sometimes embrace a pernicious hyper-individualism that sanctions free-riding on herd immunity and that cultivates indifference to the interpersonal and social harms that unvaccinated persons may cause. (shrink)

Context In response to outbreaks of vaccine‐preventable disease and increasing rates of vaccine refusal, some political communities have recently implemented coercive childhood immunization programs, or they have made existing childhood immunization programs more coercive. Many other political communities possess coercive vaccination policies, and others are considering developing them. Scholars and policymakers generally refer to coercive immunization policies as “vaccine mandates.” However, mandatory vaccination is not a unitary concept. Rather, coercive childhood immunization policies are complex, context‐specific instruments. Their (...) legally and morally significant features often differ, and they are imposed by political communities in varying circumstances and upon diverse populations. Methods In this paper, we introduce a taxonomy for classifying real‐world and theoretical mandatory childhood vaccination policies, according to their scope (which vaccines to require), sanctions and severity (which kind of penalty to impose on vaccine refusers, and how much of that penalty to impose), and selectivity (how to enforce or exempt people from vaccine mandates). Findings A full understanding of the operation of a vaccine mandate policy (real or potential) requires attention to the separate components of that policy. However, we can synthesize information about a policy's scope, sanctions, severity, and selectivity to identify a further attribute—salience —which identifies the magnitude of the burdens the state imposes on those who are not vaccinated. Conclusion Our taxonomy provides a framework for forensic examination of current and potential mandatory vaccination policies, by focusing attention on those features of vaccine mandates that are most relevant for comparative judgments. (shrink)

Background Policy decisions about childhood vaccination require consideration of multiple, sometimes conflicting, public health and ethical imperatives. Examples of these decisions are whether vaccination should be mandatory and, if so, whether to allow for non-medical exemptions. In this article we argue that these policy decisions go beyond typical public health mandates and therefore require democratic input.Methods We report on the design, implementation, and results of a deliberative public forum convened over four days in Ontario, Canada, on the topic of childhood (...) vaccination.Results 25 participants completed all four days of deliberation and collectively developed 20 policy recommendations on issues relating to mandatory vaccinations and exemptions, communication about vaccines and vaccination, and AEFI (adverse events following immunization) compensation and reporting. Notable recommendations include unanimous support for mandatory childhood vaccination in Ontario, the need for broad educational communication about vaccination, and the development of a no-fault compensation scheme for AEFIs. There was persistent disagreement among deliberants about the form of exemptions from vaccination (conscience, religious beliefs) that should be permissible, as well as appropriate consequences if parents do not vaccinate their children.Conclusions We conclude that conducting deliberative democratic processes on topics that are polarizing and controversial is viable and should be further developed and implemented to support democratically legitimate and trustworthy policy about childhood vaccination. (shrink)

Many Catholics have expressed hesitancy or resistance to being vaccinated for COVID-19, with magisterial authorities and influential Catholic organizations advocating divergent views regarding the moral liceity of the vaccines, the justification of vaccination mandates, and whether such mandates should include religious exemptions. We address each of these disputed points and argue that vaccination for COVID-19 falls within the definition of being an ordinary—and thereby morally obligatory—treatment. To that end, we offer a brief overview of the Catholic moral tradition regarding the (...) development of the distinction between ordinary and extraordinary treatment, show how the Church morally evaluates vaccination as a good act, and underline the importance of positive witnessing in supporting vaccination. (shrink)

COVID-19 vaccine requirements have generated significant debate. Here, we argue that, on the evidence available, such policies should have recognised proof of natural immunity as a sufficient basis for exemption to vaccination requirements. We begin by distinguishing our argument from two implausible claims about natural immunity: natural immunity is superior to ‘artificial’ vaccine-induced immunity simply because it is ‘natural’ and it is better to acquire immunity through natural infection than via vaccination. We then briefly survey the evidence (...) base for the comparison between naturally acquired immunity and vaccine-induced immunity. While we clearly cannot settle the scientific debates on this point, we suggest that we lack clear and convincing scientific evidence that vaccine-induced immunity has a significantly higher protective effect than natural immunity. Since vaccine requirements represent a substantial infringement of individual liberty, as well as imposing other significant costs, they can only be justified if they are necessary for achieving a proportionate public health benefit. Without compelling evidence for the superiority of vaccine-induced immunity, it cannot be deemed necessary to require vaccination for those with natural immunity. Subjecting them to vaccine mandates is therefore not justified. We conclude by defending the standard of proof that this argument from necessity invokes, and address other pragmatic and practical considerations that may speak against natural immunity exemptions. There are no data in this work. (shrink)

The purpose of this paper is to propose a middle ground in the debate over religious exemptions from measles vaccination requirements. It attempts to strike a balance between public health concerns on the one hand and religious objections on the other that avoids two equally serious errors: making religious liberty an absolute and disregarding religious beliefs altogether. Some think that the issue is straightforward: science has spoken and the benefits to public health outweigh any other concerns. The safety of the (...) community, they say, demands that everybody be vaccinated so that measles outbreaks can be prevented, but such voices often ignore the freedom of religion, which is a mistake. Using Martha Nussbaum’s work on religious liberty, this paper claims that the exemptions should be preserved if a certain level of vaccination rates can be maintained. (shrink)

Vaccine mandates can take many forms, and different kinds of mandates can implicate an array of values in diverse ways. It follows that good ethics arguments about particular vaccine mandates will attend to the details of individual policies. Furthermore, attention to particular mandate policies—and to attributes of the communities they aim to govern—can also illuminate which ethics arguments may be more salient in particular contexts. If ethicists want their arguments to make a difference in policy, they should attend (...) to these kinds of empirical considerations. This paper focuses on the most common and contentious vaccine mandate reform in the contemporary United States: the elimination of nonmedical exemptions (NMEs) to school and daycare vaccine mandates. It highlights, in particular, debates about California's Senate Bill 277 (SB277), which was the first successful recent effort to eliminate NMEs in that country. We use media, secondary sources, and original interviews with policymakers and activists to identify and evaluate three ethics arguments offered by critics of SB277: parental freedom, informed consent, and children's rights to care and education. We then turn to one ethics argument often offered by advocates of SB277: harm prevention. We note, however, that three arguments for mandates that are common in the immunization ethics literature—fairness/free-riding, children's rights to vaccination, and utilitarianism—did not play a role in debates about SB277. (shrink)

To protect public health, states require that parents have their children immunized before they are permitted to attend public or private school. But for homeschooled children, the rules vary. With the spectacular growth in the number of homeschooled students, it is becoming more difficult to reach these youth to ensure that they are immunized at all. These children are frequently unvaccinated, leaving them open to infection with diseases that are all but stamped out in the United States with immunization requirements. (...) States should encourage parents to get their homeschooled students vaccinated through enacting the same laws as those used for public school students. This could be done by enforcing current laws through neglect petitions or by requiring that children be immunized before participating in school sponsored programs. As most states require some filing to allow parents to homeschool their children, it would be easy to enact laws requiring that homeschooled children be immunized or exempted before completing registration. (shrink)

Recently, several states in the US have made it more difficult to receive nonmedical exemptions to school vaccine mandates in the hope of better orienting parents towards vaccination. However, little is known about how public-facing school staff implement and enforce mandate policies, including why or how often they steer parents towards nonmedical exemptions. This study focused on Michigan, which has recently added an additional burden for families seeking nonmedical exemptions. We used an anonymous online survey to assess Michigan public-school (...) employees (n = 157) about their knowledge, attitudes, and behaviors regarding Michigan's school enrollment vaccine mandate policy. Our main conclusions are that frontline school staff are generally knowledgeable about vaccines and immunization policy, but are at best ambivalent about their role in immunization governance, believing that other agents should be responsible for ensuring that children are vaccinated. Furthermore, some respondents indicated low vaccine confidence, which was associated with increased ambivalence about, or opposition to, their role in immunization governance. As more jurisdictions within and beyond the US consider introducing or tightening childhood vaccine mandates, it is increasingly important to understand how these policies can be improved by attending to the attitudes and roles of relevant frontline actors. (shrink)

In several countries, governments have implemented so-called ‘COVID passport’ schemes, which restrict access to venues such as bars or sports events to those who are vaccinated against COVID-19 and/or exempt vaccinated individuals from public health measures such as curfews or quarantine requirements. These schemes have been the subject of a heated debate. Concerns about inequality have played an important role in the opposition to such schemes. This article highlights that determining how COVID passports affect equality requires a much more nuanced (...) analysis than is typically assumed. I identify a range of broadly egalitarian considerations that could be affected by the introduction of COVID passport schemes. While these schemes could undermine certain aspects of equality, I argue that they could also be used to promote equality. The magnitude and severity of these different effects, both promoting and undermining equality, depend on how precisely these schemes are framed and the local context in which they are implemented. (shrink)

While all states in the United States require certain vaccinations for school attendance, all but three allow for religious exemptions to receiving such vaccinations, and 18 allow for exemptions on the basis of other deeply held personal beliefs. The rights of parents to raise children as they see fit may conflict with the duty of the government and society to protect the welfare of children. In the U.S., these conflicts have not been settled in a uniform and consistent manner. We (...) apply a test that provides a concrete and formal rubric to evaluate such conflicts. For some vaccinations, based on the individual medical characteristics of the disease and the risks of being unvaccinated, the test would suggest that permitting conscientious exemptions is ethical. However, for vaccinations protecting against other diseases that are more severe or easily transmitted, the test would suggest that the federal government may ethically impose laws that deny such exemptions. (shrink)

Marshall and O’Leary’s thoughtful response to our article suggests that dismissal policies are ethically justifiable because they might induce parents to immunize their children. This outcome is conceivable, but we have only anecdotes about how often it occurs. Such evidence became the thin reed on which the American Academy of Pediatrics rested its new policy of tolerating the practice of dismissing vaccine-hesitant parents. It seems likely that relatively few parents would agree to vaccinate because they were threatened with dismissal. (...) Other heavy-handed interventions have failed to move most such parents. When Washington state made nonmedical exemptions more difficult to obtain, nearly two-thirds of vaccine refusers were unmoved and their children remained unvaccinated. Even if dismissal threats led some parents to accept vaccines, this alone would not justify a dismissal policy. The benefits would still have to be weighed against the risks of dismissing those families who do not change their minds. (shrink)

Some vaccine-hesitant people lack epistemic trust in the COVID-19 vaccine recommendation that because vaccines have been shown to be medically safe and effective, one ought to get vaccinated. Citing what I call exception information, they claim that whatever the general safety and efficacy of vaccines, the vaccines may not be safe and effective for them. Examples include parents citing information about their children's health, pregnant women's concerns about the potential adverse effects of treatment on pregnant women, young people (...) citing their relative invulnerability to extreme COVID-19 symptoms, or members of vulnerable racial groups citing epistemic injustice, such as a lack of representation in COVID-19 vaccine trials. This paper examines the extent to which a lack of epistemic trust in vaccine recommendations, based on such exemption information, is rational. (shrink)

Public health law courses typically focus a good deal of attention on two related topics: the duty of government agencies to control the spread of communicable diseases and their use of the police power to do so. While governments sometimes take forceful actions in responding to disease outbreaks, they can also act to prevent their occurrence. Indeed, one of the great triumphs of public health in the 20th century was the development of vaccines and their widespread use, which seemed on (...) course to relegate many formerly crippling or deadly diseases to the history books. Particular success occurred with vaccinations against childhood diseases such as polio, smallpox, and measles, outbreaks of which once routinely closed schoolrooms, playgrounds, and community swimming pools. By the last quarter of the century, completion of an elaborate schedule of immunizations was not merely the standard in pediatric practice but an official requirement for school enrollment. As a result, the range of communicable diseases that had once terrified parents had become threats to be feared only in memory. (shrink)

While vaccination rates in the United States are high — generally over 90 percent — rates of exemptions have been going up, and preventable diseases coming back. Aside from their human cost and the financial cost of treatment imposed on those who become ill, outbreaks impose financial costs on an already burdened public health system, diverting resources from other areas. This article examines the financial costs of non-vaccination, showing how high they can be and what they include. It makes a (...) case for requiring those who do not vaccinate to cover the costs of outbreak caused by their choice. Such recouping is justified because the choice not to vaccinate can easily be seen as negligent. But even if it is not, that choice involves imposing costs on others, and there are good reasons to require the actors to internalize those costs. The article proposes alternative statutory and regulatory schemes to cover the costs imposed on the public purse, focusing on no-fault mechanisms. We consider both ex ante mechanisms like a tax or a fee that will go into a no-fault fund to cover the costs and ex post mechanisms like a statutory authorization for recoupment of those costs by health officials. (shrink)

Health care institutions have paid increasing attention to preventing nosocomial transmission of influenza through vaccination of health care personnel. While multifaceted voluntary interventions have increased vaccination rates, proponents of mandatory programs contend the rates remain unacceptably low. Conventional bioethical analyses of mandatory programs are inadequate; they fail to account for the obligations of nonprofessional personnel or to justify the weights assigned to different ethical principles. Using an ethics framework for public health permits a fuller analysis. The framework's focus on fairness (...) accentuates the potential differences between the risk of transmitting infection and employment status, and the need to equitably evaluate exemptions. The framework's emphasis on balancing benefits and burdens highlights the need to justify a specific goal and questions the need to exclude all nonmedical exemptions. While mandatory vaccination programs are justifiable, greater attention should be paid to their implementation. (shrink)

Background Since 2015, Michigan has required parents who request nonmedical exemptions (NMEs) from school or daycare immunization mandates to receive education from local public health staff (usually nurses). This is unlike most other US states that have implemented mandatory immunization counseling, which require physicians to document immunization education, or which provide online instruction. -/- Purpose To attend to the activity and dispositions of the public health staff who provide “waiver education”. -/- Method This study reports results of focus group interviews (...) with 39 of Michigan's vaccine waiver educators (37 nurses), conducted during 2016 and 2017, and analyzed in 2018. -/- Findings Four themes emerged from analysis of the transcripts of these interviews: Participants had (1) complex and nuanced observations and evaluations of parents' judgments and feelings about vaccines and vaccine education; (2) sympathetic attitudes about alternative vaccine schedules; (3) critical and supportive evaluations of institutional policies and the background political context of immunization education; and (4) consistent commitments to respect parents, affirm their values, and protect their rights. Discussion These results show that public health nurses are sensitive to the burdens mandatory immunization education places on families, the motivations for parents' requests for nonmedical exemptions, and the values implicated by personal immunization decisions and government immunization policies. In light of the unique training, experiences, and public reputation of nurses, there is good reason for additional investigation into the roles that nurses can play in immunization education and in vaccine mandate policies, more generally. (shrink)

Lockdowns and quarantines have been implemented widely in response to the COVID-19 pandemic. This has been accompanied by a rise in interest in the ethics of ‘passport’ systems that allow low-risk individuals greater freedoms during lockdowns and exemptions to quarantines. Immunity and vaccination passports have been suggested to facilitate the greater movement of those with acquired immunity and who have been vaccinated. Another group of individuals who pose a low risk to others during pandemics are those with genetically mediated resistances (...) to pathogens. In this paper, we introduce the concept of genomic passports, which so far have not been explored in the bioethics literature. Using COVID-19 as an illustrative example, we explore the ethical issues raised by genomic passports and highlight differences and similarities to immunity passports. We conclude that, although there remain significant practical and ethical challenges to the implementation of genomic passports, there will be ways to ethically use them in the future. (shrink)

Health care institutions have paid increasing attention to preventing nosocomial transmission of influenza through vaccination of health care personnel. While multifaceted voluntary interventions have increased vaccination rates, proponents of mandatory programs contend the rates remain unacceptably low. Conventional bioethical analyses of mandatory programs are inadequate; they fail to account for the obligations of nonprofessional personnel or to justify the weights assigned to different ethical principles. Using an ethics framework for public health permits a fuller analysis. The framework's focus on fairness (...) accentuates the potential differences between the risk of transmitting infection and employment status, and the need to equitably evaluate exemptions. The framework's emphasis on balancing benefits and burdens highlights the need to justify a specific goal and questions the need to exclude all nonmedical exemptions. While mandatory vaccination programs are justifiable, greater attention should be paid to their implementation. (shrink)

We would like to thank each of the commentators on our feature article for their thoughtful engagement with our arguments. All the commentaries raise important questions about our proposed justification for natural immunity exemptions to COVID-19 vaccine mandates. Thankfully, for some of the points raised, we can simply signal our agreement. For instance, Reiss is correct to highlight that our article did not address the important US-centric considerations she helpfully raises and fruitfully discusses. We also agree with Williams about (...) the need to provide a clear rationale for mandates, and to obtain different kinds of data in support of possible policies.Unfortunately, we lack the space to engage with every one of the more critical comments raised in this rich set of commentaries; as such, in this response, we shall focus on a discussion of hybrid immunity, which underlies a number of different arguments evident in the commentaries, before concluding with some reflections responding to Lipsitch’s concern about the appropriate standard of proof in this context. (shrink)

In their thoughtful, nuanced and interesting discussion, Jonathan Pugh, Julian Savulescu, Rebecca Brown and Dom Wilkinson argued that officials should recognise proof of prior infection as a valid exemption from vaccination requirements.1 This commentary agrees with parts of their analysis, but argues that the case for the exemption is less clear than the authors suggest, and the better approach is to allow officials flexibility: an exemption for natural immunity may be appropriate or may not. In part, the (...) disagreements may stem from different experiences in different societies. The authors are in the UK, and their experience may differ from the USA in multiple ways, three very glaring. First, the UK broadly used the AstraZeneca vaccine, which has higher risks than the mRNA vaccines, so our assessment of vaccine risks differs. Second, the UK has universal health insurance, so some of the access to testing issues that I raise concerns about may not apply there. And third, the risk of fraud or misrepresentation may be less in the UK—and other countries—than in the USA, where real concerns about, for example, fake vaccine cards have led to multiple arrests.2 Another issue is that information about COVID-19 changes fast—what was known when the authors wrote may no longer fit the current picture. In their article, the authors argue that it is ethically imperative that COVID-19 mandates exempt those with natural immunity. The authors argue that those who have become immune through infection are ‘potentially equivalent’ to those who were vaccinated, and refusing them an exemption is ethically unjustified—they call this the ‘unnaturalistic fallacy’. The authors convincingly conclude that existing data suggest that previous infection leads to durable immunity for at least several months and protects against reinfection. The …. (shrink)

Parental decision making is necessary for contracting medical interventions that require personal risk–benefit evaluation, and for overseeing matters of education. In the nineteenth century, exemptions from obligatory vaccination were granted for religious and conscientious reasons. Then and today, religion and moral values play marginal roles in vaccine hesitancy and denialism. Rather, the key values invoked by vaccine hesitants and denialists are liberty and pluralism. Neither is compatible with limiting adolescents’ choice. Because vaccination does not require assessment of personal (...) medical risks, because it does not need to occur within the sphere of the doctor–patient relationship, and because the risk involved is within the range of their daily activities, adolescents have the right to free access to vaccination without legal requirement of parental involvement. Drawing on the development of Common Law, and on the development of respect for personal conscience in the history of ideas, this paper does not promote an argument that grants public health an overriding moral power. Rather, this paper rejects the presumption that vaccination of adolescents might involve a conflict between parental authority and public health. Free access to vaccination is compatible with the law and ethics of adolescents’ evolving autonomy in relation to healthcare. (shrink)

One of the major objectives in a democratic state is ensuring health security of the citizens including combating epidemic diseases. The subject matter of this article is the presentation and analysis of legal regulations regarding preventive vaccination in Poland, in particular the aspect of imposing a legal obligation and restricting parents’ right to express consent for medical intervention. The reflections made herein are aimed at finding an answer to the question whether the adopted legal solutions are admissible in a democratic (...) state with regard to ensuring health security. The purpose of the analysis is also to assess whether the abovementioned legal regulations have been formulated in a clear way and do not raise interpretation doubts and, consequently, whether they are comprehensible to the parents obliged to comply with them. As it follows from analysis of the legal provisions, parents must not refuse to subject a child to obligatory preventive vaccination and their consent is not required by law, both as regards the medical qualifying examination to exclude contraindications to performing vaccination and the vaccination itself. It is a legal obligation, from which exemption is only possible on grounds of certain medical conditions that would render vaccination inadvisable. The legal provisions that concern obligatory preventive vaccination in Poland, including in particular those referring to its enforceability, have not been formulated in a way that is sufficiently comprehensible to parents who are under the obligation of complying with them, irrespective of the fact that the language of the provisions of law should be clear and raise no interpretative doubts. In a democratic state the protection of public health against epidemic hazards justifies the implementation of legal solutions that restrict an individual’s freedom of self-determination, thus limiting the right of patients or their statutory representatives to grant or refuse consent for a medical intervention in the form of preventive vaccination – the purpose of this legal solution being to prioritize the safeguarding of state health security. It is vitally important to engage in a social dialogue with the purpose of convincing the public of the need for vaccination, its significance and its implementation for the better good. (shrink)

Can parents who choose not to vaccinate their children be held legally liable for any harm that results? The state of laboratory and epidemiological understanding of a disease such as measles makes it likely that a persuasive causal link can be established between a decision to not vaccinate, a failure to take appropriate precautions to isolate a non-vaccinated child who may have been exposed to measles from highly vulnerable persons, and a death. This paper argues that, even if a parent (...) chooses to not vaccinate a child under a state law permitting exemptions, that decision does not create complete protection against liability for the adverse consequences of that choice. (shrink)

Consider this hypothetical scenario involving a choice not to vaccinate a child. Ms. S has a niece who is autistic. The girl's parents are suspicious that there is some relationship between her autism and her Measles Mumps and Rubella vaccination. They have shared their concerns with Ms. S. She then declines to have her own daughter, Jinny S., vaccinated with the MMR vaccine. To bypass the state's mandatory vaccination requirement, Ms. S claims a state-legislated philosophical exemption, whereby she (...) simply attests to the fact that she is opposed to vaccinating her daughter due to a conscientiously held belief. At the age of four, Jinny goes on a trip by airplane to Germany with her mother. After returning to the United States, she attends daycare despite having some mild cold symptoms. Subsequently, she develops a classic measles rash, at which point her mother brings her to a pediatrician and keeps her home from daycare. (shrink)

This article examines the rise of the anti-vaccination movement, the proliferation of laws allowing parental exemptions to mandatory school vaccines, and the impact of the movement on immunization rates for all vaccines. It uses the ongoing debate about the Human Papillomavirus vaccine as an example to highlight the ripple effect and consequences of the anti-vaccine movement despite robust evidence of the vaccine's safety and efficacy. The article scrutinizes how state legislatures ironically promote vaccination while simultaneously deferring to (...) the opposition by promulgating broad opt-outs from mandatory vaccine laws. This article concludes by offering an alternative legislative approach to specifically combat the anti-vaccine movement's impact on HPV vaccination rates. Lowering the age of consent has not been widely attempted or proposed and provides an alternative statutory mechanism to push back against vaccine resistance. (shrink)

Australian states exclude unvaccinated children from early education and care via ‘No Jab No Play’ policies, but some offer exemptions for the socially disadvantaged. Such mandatory vaccination policies provoke heated arguments about morality and potential downstream impacts, and the politics of which kinds of people get exempted from mandates are often fraught. Synthesising existing frameworks for considering the role of moral principles and rational-technical justifications in policymaking, we show how the same values can be the focus of both ‘rational-instrumental’ and (...) ‘morality’ frames, while ‘pragmatic’ approaches are crowded out by high epistemic or moral certainty. (shrink)

Worldwide there are currently over 1200 research studies being performed on the topic of COVID-19. Many of these involve children and adults over age 65 years. There are also numerous studies testing investigational vaccines on healthy volunteers. No research team is exempt from the pressures and speed at which COVID-19 research is occurring. And this can increase the risk of honest error as well as misconduct. To date, 33 papers have been identified as unsuitable for public use and either retracted, (...) withdrawn, or noted with concern. Asia is the source of most of these manuscripts (n=19; 57.6%) with China the largest Asian subgroup (n=11; 57.9%). This paper explores these findings and offers guidance for responsible research practice during pandemics. (shrink)

Some parents take advantage of legal exemptions for the measles-mumps-rubella vaccine. While there are a variety of reasons parents do so—including having children with medical conditions that make vaccination medically unsafe—some parents appear to be driven, at least in part, by beliefs that vaccines cause a variety of diseases or conditions, such as autism. Those who delay or refuse the MMR vaccine because of false beliefs about its side effects elicit a strikingly strong response from many who endorse (...) MMR vaccine mandates. Accusations of moral wrongdoing, expressions of anger, indignation, resentment, or disgust frequently appear in social... (shrink)

According to G E Moore,1 we commit the naturalistic fallacy when we infer ‘x is good’ from non-evaluative premises involving x such as ‘ x is pleasant’ or ‘ x is desired’. On Moore’s view, the mistake is to think that we can reduce moral goodness to anything else or explain it in any other terms. We cannot analyse ‘good’, Moore thought, because goodness is simple, non-natural and sui generis. If Moore were alive today, and if he were to ask (...) contemporary bioethicists the right questions, he would probably find that many of them commit the naturalistic fallacy when they move from empirical premises to normative conclusions or when they articulate complex notions of the good. Pugh et al 2 might commit the naturalistic fallacy themselves when they conclude that people with natural immunity to COVID-19 should be exempt from vaccine mandates because such exemptions would achieve desired public health benefits. Moore would probably find me guilty of committing the naturalistic fallacy if I were to present my arguments against such exemptions. A reanimated Moore would find that the naturalistic fallacy pervades bioethics and public health. In contrast, as I shall argue, the un naturalistic fallacy is probably nowhere to be found. In this commentary, I explain what the so-called unnaturalistic fallacy really is and raise doubts about whether anyone really commits it. Decades after Moore published Principia Ethica, Bernard Williams observed that the naturalistic fallacy is unfortunately named since it is neither a fallacy nor an argumentative tendency unique to ethical naturalists.3 Ethical non-naturalists make the same mistake—if it is a mistake—when they move from, say, ‘x is commanded by the gods’ to ‘x is good’. Just as Moore’s ‘naturalistic fallacy’ misnames, Pugh et al ’s ‘unnaturalistic fallacy’ misleads. To be …. (shrink)

Nonpharmaceutical interventions to minimize the transmission of the severe acute respiratory syndrome coronavirus 2 are necessary because we currently lack a vaccine or specific treatments. Healthcare facilities have adopted visitor restrictions and masking requirements. These interventions should be evaluated as public health measures, focusing on their efficacy, the availability of less-restrictive alternatives, and the minimization of the burdens and their balance with the benefits. These interventions, as well as exceptions, can be justified by the same analysis. For example, visitor (...) restrictions are sound, as are exceptions for women in labor, adults with disabilities, minor children, and individuals who are dying. In implementing these policies, specific rules are preferable to general principles because they are more efficient and reduce possible bias. There should, however, be appeal mechanisms and retrospective review processes. Evaluating requests for medical exemptions to masking requirements is particularly difficult, given the prevalence of nonmedical objections, false claims of medical exemptions, and a lack of objective medical criteria. Requiring written statements by licensed healthcare providers that undergo subsequent substantive review may therefore be justified. (shrink)

:This article takes up a game-theoretic perspective on California’s recently passed bill that closes all nonmedical exemptions for school-mandated vaccination. Such a perspective characterizes parental decisions to vaccinate their children as a collective action problem and reveals the presence of an incentive to free ride—to enjoy the benefits of others’ efforts to vaccinate their children without vaccinating one’s own. This article defends California’s legislation as a reasonable means of overcoming the free rider problem and of ensuring that the burdens of (...) vaccination are shared equally. (shrink)

This article analyzes the Supreme Court’s “shadow docket” Free Exercise cases relating to COVID-19. The paper highlights the decline of deference, the impact of exemptions, and the implications of the new doctrine for vaccine and other public health laws.

Pox parties are a controversial alternative to vaccination for diseases such as chickenpox. Such parties involve parents infecting non-immune children by exposing them to a contagious child. If successful, infection will usually lead to immunity, thus preventing infection later in life, which, for several vaccine-preventable diseases, is more severe than childhood infection. Some may consider pox parties more morally objectionable than opting out of vaccination through non-medical exemptions. In this paper, I argue that this is not the case. Pox (...) parties involve immediate risk of harm for children and reduce future harms, whereas opting out of vaccination places children at long-term risk of harms that increase with time, at least for some pathogens. Regarding harm to others through onward transmission of infection, this can be easily prevented in the case of pox parties—given the relatively controlled timing of infection—by quarantining attendees after the party, whereas opting out of vaccination involves risks to others that are more difficult to control. I defend three criteria for an ethical pox party: that the disease is sufficiently low risk, that parents consent to their child’s attendance and that children exposed to infection are quarantined and isolated appropriately. I argue that, if these criteria are met, pox parties are morally preferable to non-vaccination; such parties involve less risk to non-consenting others and, for some pathogens in some cases, even involve less risk for the children who participate. Thus, policies that permit non-medical exemption to vaccination should also permit ethical pox parties. Alternatively, if pox parties are not permitted, then vaccination should be mandated for those without medical contraindication. (shrink)